How much can we trust our clinical assessment of peritonitis?
A 26 year old man recently presented to our trauma bay with a thoracoabdominal stab wound. He was hemodynamically stable, however his exam was notable for classic peritonitis--his abdomen was diffusely tender, and he had rebound and guarding. Based on his exam, we elected to take him to the operating room for an exploratory laparotomy. A standard midline incision was made, and all four quadrants were packed. No injury to the diaphragm, organs, or abdominal wall was found. The patient's abdomen was closed, and the remainder of his hospital course was unremarkable.
This negative laparotomy prompted us to question how much we should trust our clinical assessment of peritonitis. To address this exact issue, trauma surgeons at Los Angeles County and University of Southern California Medical Center performed a retrospective review of all negative laparotomies presented at their Morbidity and Mortality conference between 2003 and 2008. A total of 1871 laparotomies were performed, and 73 of those were negative. Interestingly, this group found that peritonitis was the primary indication for laparotomy in 55% of negative explorations.
Cases such as ours and reviews such as this suggest that for some patients with presumed peritonitis further imaging, DPL, or perhaps continued observation may be more appropriate than exploratory laparotomy. However, one must balance this with the potential for missed injury. Further work is clearly warranted to determine when peritonitis on physical exam may not be a good indication for laparotomy
Schnuriger B, Lam L, Inaba K, Kobayashi L, Barbarino R, Demetriades D. Negative laparotomy in trauma: are we getting better? 2012. Am Surg. 78(11): 1219-23.
submitted by Dr. Erica Carlisle
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